Relative Energy Deficiency in Sport (RED-S) in Adolescents - A Practical Review.

There are many immediate and longer-term physical, psychological and metabolic benefits of being active during adolescence. These benefits exist when exercise and physical activity are undertaken in a state of energy balance. When exercise occurs in an environment of low energy availability, this is currently termed relative energy deficiency in sport and there are potential significant negative effects on mental well-being, bone, endocrine and metabolic health. Therefore, relative energy deficiency in sport may present to many different specialists or allied health professionals depending upon the symptoms or reasons for seeking help, which include injury, such as bone stress or soft tissue problems, irregular or absent menstruation, stress, anxiety or low mood, or sporting underperformance as examples. The promotion of physical activity in adolescence is a critical part of public health strategy. In parallel with this positive public health message, there needs to be an increase in the awareness of, and education about, relative energy deficiency in sport for those working with and looking after adolescents.This review provides an up to date, practical evidenced based guide on the recognition, investigation and management of relative energy deficiency in sport in the adolescent, both male and female.

Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions.

INTRODUCTION: The benefits of physical activity for people living with long-term conditions (LTCs) are well established. However, the risks of physical activity are less well documented. The fear of exacerbating symptoms and causing adverse events is a persuasive barrier to physical activity in this population.This work aimed to agree clear statements for use by healthcare professionals about medical risks of physical activity for people living with LTCs through expert consensus. These statements addressed the following questions: (1) Is increasing physical activity safe for people living with one or more LTC? (2) Are the symptoms and clinical syndromes associated with common LTCs aggravated in the short or long term by increasing physical activity levels? (3) What specific risks should healthcare professionals consider when advising symptomatic people with one or more LTCs to increase their physical activity levels? METHODS: Statements were developed in a multistage process, guided by the Appraisal of Guidelines for Research and Evaluation tool. A patient and clinician involvement process, a rapid literature review and a steering group workshop informed the development of draft symptom and syndrome-based statements. We then tested and refined the draft statements and supporting evidence using a three-stage modified online Delphi study, incorporating a multidisciplinary expert panel with a broad range of clinical specialties. RESULTS: Twenty-eight experts completed the Delphi process. All statements achieved consensus with a final agreement between 88.5%-96.5%. Five 'impact statements' conclude that (1) for people living with LTCs, the benefits of physical activity far outweigh the risks, (2) despite the risks being very low, perceived risk is high, (3) person-centred conversations are essential for addressing perceived risk, (4) everybody has their own starting point and (5) people should stop and seek medical attention if they experience a dramatic increase in symptoms. In addition, eight symptom/syndrome-based statements discuss specific risks for musculoskeletal pain, fatigue, shortness of breath, cardiac chest pain, palpitations, dysglycaemia, cognitive impairment and falls and frailty. CONCLUSION: Clear, consistent messaging on risk across healthcare will improve people living with LTCs confidence to be physically active. Addressing the fear of adverse events on an individual level will help healthcare professionals affect meaningful behavioural change in day-to-day practice. Evidence does not support routine preparticipation medical clearance for people with stable LTCs if they build up gradually from their current level. The need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms. As part of a system-wide approach, consistent messaging from healthcare professionals around risk will also help reduce cross-sector barriers to engagement for this population.

The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management.

PURPOSE OF REVIEW: Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5-10,000 (Chiu et al. Mayo Clin Proc. 89(1):34-42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476-85, 4). RECENT FINDINGS: The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30-50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149-58, 147, Murdoch et al. N Engl J Med. 286(15):804-8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308-1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS. Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the "systemic features score" (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.

The Effect of Dutasteride on Magnetic Resonance Imaging Defined Prostate Cancer: MAPPED-A Randomized, Placebo Controlled, Double-Blind Clinical Trial.

PURPOSE: Dutasteride, which is licensed for symptomatic benign prostatic hyperplasia, has been associated with a lower progression rate of low risk prostate cancer. We evaluated the effect of dutasteride on prostate cancer volume as assessed by T2-weighted magnetic resonance imaging. MATERIALS AND METHODS: In this randomized, double-blind, placebo controlled trial, men with biopsy proven, low-intermediate risk prostate cancer (up to Gleason 3 + 4 and PSA up to 15 ng/ml) who had visible lesion of 0.2 ml or greater on T2-weighted magnetic resonance imaging sequences were randomized to daily dutasteride 0.5 mg or placebo for 6 months. Lesion volume was assessed at baseline, and 3 and 6 months with image guided biopsy to the lesion at study exit. The primary end point was the percent reduction in lesion volume over 6 months. This trial was registered with the European Clinical Trials register (EudraCT 2009-102405-18). RESULTS: A total of 42 men were recruited between June 2010 and January 2012. In the dutasteride group, the average volumes at baseline and 6 months were 0.55 and 0.38 ml, respectively and the average reduction was 36%. In the placebo group, the average volumes at baseline and 6 months were 0.65 and 0.76 ml, respectively, and the average reduction was -12%. The difference in percent reductions between the groups was 48% (95% CI 27.4-68.3, p <0.0001). The most common adverse event was deterioration in erectile function, which was 25% in men randomized to dutasteride and 16% in men randomized to placebo. CONCLUSIONS: Dutasteride was associated with a significant reduction in prostate cancer volume on T2-weighted magnetic resonance imaging compared to placebo.

Role of magnetic resonance imaging in defining a biopsy strategy for detection of prostate cancer.

Prostate cancer is the second most common male cancer worldwide. It has a broad spectrum, from low-risk, clinically indolent disease, to high-risk aggressive cancer. This variety conveys certain diagnostic and management challenges. The use of prostate-specific antigen as a screening test for prostate cancer is increasing the diagnosis of low-grade, low-volume disease. By targeting biopsies towards suspicious areas on multiparametric magnetic resonance imaging, we can accurately diagnose clinically significant prostate cancer, reducing identification of low-risk, clinically indolent disease. This could avoid the radical treatment of histopathological cancer that might never have become clinically apparent. In the present review, we consider the use of multiparametric magnetic resonance imaging to inform the biopsy strategy. By identification of suspicious lesions on multiparametric magnetic resonance imaging, biopsy targets can be identified, and the sampling bias associated with blind standard transrectal prostate biopsy can be reduced. We consider the reliability of these radiological lesions for detection of clinically significant prostate cancer, and the methods of targeting them to ensure the radiological lesion is accurately sampled. Evidence suggests that targeted biopsy is efficient and accurate for diagnosis of clinically significant prostate cancer. By rationalizing diagnosis, and subsequently preventing overtreatment of clinically insignificant disease, magnetic resonance imaging-informed prostate biopsy can provide a method for streamlining the diagnostic pathway in prostate cancer.

The role of MRI in active surveillance of prostate cancer.

PURPOSE OF REVIEW: The aim of active surveillance is to avoid radical treatment and its side-effects in men who have truly low risk prostate cancer, whilst offering radical treatment to those men who are at higher risk of local progression or metastatic disease. The traditional tools used to attribute these risk categories are prostate specific antigen, digital rectal examination, transrectal biopsy and their repeated application over time. MRI is emerging as a tool which may be able to more accurately determine the risk of significant disease at diagnosis and progression of disease over time. This review will examine the role of MRI in men on active surveillance. RECENT FINDINGS: The body of work on MRI as a tool for the detection of significant cancer is rapidly increasing, both in men undergoing initial assessment for prostate cancer risk, and in those who have low risk cancer on standard transrectal ultrasound guided biopsy. In addition, the use of MRI as a tool to detect change in prostate cancer is being explored by a small number of groups. SUMMARY: Multiparametric MRI is a useful tool in the initial assessment and surveillance of men who choose to avoid radical treatment when first diagnosed with localized prostate cancer.

Pre-sternal mass with a congenital sternal defect: a rare presentation.

Anterior chest wall and anterior mediastinal infections are very rare in children with no predisposing thoracic surgery. Congenital sternal defects occur as a result of incomplete ossification of the sternal bone, and show a wide range of severity. We present the case of a 15-month-old boy who presented to the A&E department with an anterior chest-wall mass. After investigation, it was found to be an infective mass, with extension into the anterior mediastinum, through a previously undiagnosed 5 mm congenital sternal defect identified peri-operatively. After antibiotic therapy and surgical management the patient made complete recovery with no recurrence or complications within 6 months of review.